Most truths are so naked that people feel sorry for them and cover them up, at least a little bit.
-Edward R. Murrow “Doctor, I should not have cancer! I never smoked! I am only 45 years old! It doesn’t make sense!”
The patient and his wife sit stunned and frightened.
My new patient is absolutely correct … he does not fit the traditional profile of patients with cancer of the tonsil.
When I started training in the 1980s, the vast majority of our patients with these cancers were older men who had spent their lives smoking heavily and drinking hard. These were men that had out-lived many of their contemporaries despite wartime service, difficult lives, and chronic illness; now they were saddled with the burden of difficult, disfiguring, and often ineffective cancer treatment.
My patient today, though, fits the new profile as a younger, healthy, non-smoking person.
Recent research has confirmed the shift in the dominant demographic for tonsil cancers from older, smoking men to younger, non-smoking men. The cause for this shift is the Human Papilloma Virus (HPV), particularly HPV-16, HPV-18, and HPV-31.
in the Journal of Clinical Oncolog
y compared 17,625 possibly HPV-related cancers to 28,144 possibly HPV-unrelated cancers. Since the 1970s, the incidence of HPV-related cancer has increased by 53 percent. The good news is that HPV-related cancers are much more responsive to radiation therapy and have better treatment outcomes.
“But, Doctor, why did I get the cancer?”
Although the answer is fairly clear, this question remains a difficult one for me. The most common cause for HPV infection is through sexual contact. A study
in the New England Journal of Medicine
found that the greater the number of vaginal sex partners and the greater the number of oral sex partners, the greater the likelihood of developing one of these cancers.
I look at my new patient and his wife. To me, this does not seem to be the right time to discuss epidemiology.
Or sex. “The cancer is most likely from an HPV viral infection you picked up many years ago. We have a very good chance of curing your cancer.”
He looks relieved, then blurts out, “Do my kids have a higher likelihood of getting one of these cancers because I had one?”
I'm not certain. “I don’t know, but we hope that these kinds of infections and their associated cancers will be eliminated in future generations because of the HPV immunizations.”
I have to admit that I am still not comfortable knowing how and when to discuss this topic with my cancer patients. Clearly, though, we will be having more and more of these conversations in the future.
||The following is feedback received for this blog:|
Dear Doctor, usually it is the other way around, the patient is embarrassed to talk to the doctor. What we need is everyone feeling less embarrassed, and you certainly do not have to feel embarrassed online. I would like to have more specific information about this tonsil cancer and what exactly may cause it. I can read between the lines, but I would like to have this kind of info straight up....so to speak.
I presume you get this kind of cancer during oral sex, but is it oral sex with a female, a male or both? As a female I have always worried about passing on a yeast infection to the performing partner, although that never happend to me, it happened so a few people I knew when their husbands came down with a bad case of thrush. I could put two and two together and kind of figured out how it may have happened.
Also, for women, and this has been my experience, I would usually get a bladder infection, something I am prone too, after receiving oral sex. After avoiding oral sex, my incidence of bladder infection is way, way down. I really think there is a link, and women seem to have bladder infections a lot.
I will come out and say it, I think most people these days engage in oral sex, for some it is even a way to avoid pregnancy and other STDs, but I could be wrong, about the STDs that is.
We need an open to the point information about this subject. I would feel terrible if somehow I infected my sex partner with cancer! Darn...everything that is fun is either illegal or bad for you, or both!
I wish there was a simple explanation, but there is not. We do know from the New England Journal of Medicine article that people who have had >25 vaginal or >5 oral partners had 3X the risk of developing one of these cancers than people who had <6 vaginal or no oral partners. In addition, patients who had a positive blood test demonstrating the L1 antigen of HPV-16 (a very sensitive test for prior HPV-16 infection) were 32X more likely to have one of these cancers than people who did not test positive.
In patients who later develop these cancers, part of the virus’s genetic material becomes incorporated into the cells in the tonsil region in the same way it is incorporated in the cervix of women who develop cervical cancer. If a person is immunized before sexual exposure to HPV, the infection never happens and the genetic material is never incorporated.
I don’t think I am too embarrassed to talk about these issues with patients, but it certainly is not what most ENT doctors spend their days discussing with their patients! My concern is prying into the buried stories and potential land mines of a patient’s sexual history at a time when the biggest priority is developing a cancer treatment plan. On the other hand, the more information we gather, the better we might potentially be able to help people in the future. I applaud the researchers at Johns Hopkins who wrote the NEJM paper for their thoroughness in assembling sexual history data.
I appreciate all of your comments, but, for some of them, I would refer you to my fellow Froedtert & Medical College of Wisconsin blogger, Margarita Kressin, MD at Sexual Healing. I might try to tackle some of your other comments but that truly would be embarrassing!
Has any research been performed that explores the effectiveness of the HPV vaccine in preventing these oral/throat cancers?